Laboratory Challenges with TNI Implementation and Laboratory Audits

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1 Laboratory Challenges with TNI Implementation and Laboratory Audits December 14, 2017 Dr. Donna Ferguson, Director, Monterey County Public Health Laboratory Dr. Martina McGarvey, Director, Pennsylvania Dept. Environmental Protection Laboratories Dr. David Kimbrough, Manager, Pasadena Water and Power Laboratory 1

2 California s Challenge with Implementing New Regulations Based on TNI In 1988, the California Environmental Laboratory Improvement Act established the State s Environmental Laboratory Accreditation Program (ELAP) to provide evaluation and accreditation of environmental testing laboratories ELAP accredits nearly 600 in-state and 100 out-of-state labs In 2016 ELAP decided to adopt regulations based on the 2016 TNI Standard, Volume 1 In August 2017 ELAP released Preliminary Draft Regulations (PDR) that were reviewed by labs Labs submitted comments to ELAP on PDR; still under review Revised regulations may not be adopted until mid to late 2018 In the meantime, labs must proceed with adopting TNI 2

3 Challenges with ELAP/TNI Audits In past years, audits were conducted by ELAP staff Recently, ELAP hired new staff and contracted with third party assessors to provide TNI gap analysis to help labs meet proposed draft regulations This fall ELAP conducted practice assessments at a few labs in Central Valley region using third party assessors 3

4 APHL QI Forum Call Objectives Laboratories in California are concerned about adopting TNI given uncertainties about the final regulations and changes in auditing process Objectives Gain further knowledge about TNI implementation and audits Lessons learned from labs in California recently inspected by third party auditors Guidance from TNI expert lab, Pennsylvania Department of Environmental Protection Laboratories 4

5 Challenges for Monterey County Health Department Laboratory Quality Systems Manual need guidance on language, format, amount of detail required Daily QCs logs - are written procedures required? Daily temperature, and ph and conductivity checks on reagent water Lack procedures, except SOPs for actual sample analysis Only recording daily values on log sheet Perform pipette calibration checks quarterly instead of annually Takes one analyst about 10 hours to check all pipettes Test reports to include start time of sample analysis for tests with holding times 72 hours or less. Required for 12 of our 23 methods. We do not have an interface from our LIMS system to our analytical computers. This is done by manually when entering results. 5

6 California Labs Audit Experience Merced and Kings Counties Public Health Laboratories Background Both labs share the same laboratory director and were recently inspected by third party (non-elap) auditors Audit Audit based on TNI standards Both labs performed well in meeting TNI technical requirements but need to work on management requirements Audits were much longer and more rigorous than past ELAP inspections Positive experience overall 6

7 California Labs Audit Experience cont. Lessons Learned Prepare audit packets to demonstrate traceability Similar to CLIA Quality Systems Review Document traceability of 10 samples (per year) For each sample, make copies of requisition, worksheet, QC of all equipment, temp charts, etc used during sample analysis and reporting. Record serial & lot #s on worksheets, including lot # of disposable pipets If possible, create a single document/database containing all QA/QC data Staff should prepare to be interviewed If your lab uses IDEXX for bacteria testing but are not performing membrane filtration (MF), you need to document that you do NOT perform MF. Be aware that Colilert 18 and 24 have different storage temperature requirements. TNI certification is not affordable/economical for labs with revenues below $10,000/year 7

8 California Labs Audit Experience cont. San Joaquin County Public Health Laboratory Positive experience with third party auditor Length of audit longer than previous ELAP inspections Lab was judged based on mostly ELAP requirements, not TNI No TNI gap analysis performed Lab staff were interviewed 8

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27 Quality Improvement through TNI Standard Implementation and Audits A State s Story PA DEP Perspective December 14, 2017 Tom Wolf, Governor Patrick McDonnell, Executive Secretary 27

28 Quality Improvement Stories Why PA implemented the TNI Standard and Quality (Management) System Approach? Similar to other states? Getting started to implement the TNI Standard What happens when we have FINDINGS in the audit process? How do we afford accreditation fees? 28

29 Purpose of Program Laboratory Activities Accreditation Program Activities The laboratory accreditation program (LAP) was established to protect the public health, safety, welfare, and the environment by ensuring the accuracy, precision, and reliability of data generated by environmental laboratories. An accredited laboratory will more likely generate data of appropriate quality for a particular analysis because of its quality system. Source: 25 Pa Code Scope 29

30 Quality (Management) System Approach Developed using a consensus process that included the perspectives of multiple stakeholders including EPA, laboratories and state agencies. Used a recognized international standard for the competency of laboratories (ISO/IEC 17025) as the basis. Added additional specificity to address issues associated with environmental testing. Focus is on generation of authentic data (i.e., data of known and documented quality generated according to accepted professional practices of the industry). 30

31 Why the TNI Standard A 501(c)3 non-profit organization. A member organization managed by a Board of Directors. Over 1000 members A voluntary consensus standards development organization accredited by the American National Standards Institute (ANSI). 31

32 Why the TNI Standard The authority to administer an accreditation program comes from each participating state s statutes and regulations. PA Laboratory Accreditation Act 2002 CA State Water Resources Control Board (State Water Board) ELAP Regulations July 2017 Preliminary draft EPA continues to have a key oversight function for drinking water. TNI provides the infrastructure to facilitate communication and consistency. 32

33 Guiding Principles of TNI Standard Flexible: Allow laboratories freedom to use their experience and expertise in performing their work and allow for new and novel approaches. Specify the What and avoid where possible the How To. Auditable: Sufficient detail so that the assessors can evaluate laboratories consistently. Practical and Essential: Necessary policies and procedures that should not place an unreasonable burden upon laboratories. Widely Applicable: Applicable to laboratories regardless of size, complexity and scope of services. Appropriate: Ensure that data is of known quality and that the quality is adequate for the intended use. 33

34 TNI Standard TNI Standard Requirements Management Technical Records QA Manual Personnel QC Analyze 2 PT samples per year and pass 2 out of 3 Assessment every 2 years 34

35 TNI STANDARD Uses ISO/IEC quality system approach, Adds specificity to improve clarity and help with consistency for environmental testing, Allows flexibility in meeting requirements, Represents best professional practice, and Allows for multiple Accreditation Bodies to implement consistently. Includes data integrity component missing from ISO Internal Audit requirements for frequency, timeliness, and notification to affected clients (V1M2:4.15.5) Data Integrity Investigations must be confidential and documented (V1M2: 4.16) Data Integrity Training requirements for all employees (V1M2: 5.2.7) 35

36 Organization of TNI Laboratory Std Module 1: Proficiency Testing Module 2: Quality Systems General Requirements Module 3: Asbestos Testing Module 4: Chemical Testing Module 5: Microbiological Testing Module 6: Radiochemical Testing Module 7: Toxicity Testing 36

37 Quality System Module Section 4: Management Requirements Implementation of a quality system Management requirements Documents and records Internal assessments System controls and improvements Comparable to ISO 9000, these requirements are good management practices to ensure analyses are performed in an orderly and structured way. 37

38 Quality System Module Section 5: Technical Requirements Technical competence of staff Validity and appropriateness of test methods Traceability of measurements Instrument calibration Testing environment Sampling, handling and transportation of samples Quality assurance of test data Reporting These requirements focus on ensuring reliable and accurate data. 38

39 Advantages of TNI NELAP Uses a consensus standard that is widely recognized as the gold standard for environmental laboratory accreditation. Relies on peer oversight to ensure all participating ABs are competent to operate accreditation programs. Utilizes TNI resources (assessor training, national database, Fields of Proficiency Testing, webinars, etc.) to leverage state resources. Membership gets to fully participate in the process and help guide the future. 39

40 What Does a Standard Look Like 4.14 Internal Audits (ISO/IEC 17025:2005(E), Clause 4.14) The laboratory shall periodically, and in accordance with a predetermined schedule and procedure, conduct internal audits of its activities to verify that its operations continue to comply with the requirements of the management system and this International Standard. The internal audit shall address all elements of the management system, including the testing activities. It is the responsibility of the quality manager to plan and organize audits as required by the schedule and requested by management. Such audits shall be carried out by trained and qualified personnel who are, wherever resources permit, independent of the activity to be audited. 40

41 TNI Resources Course : Implementing the 2009 TNI Standard The objective of this course is to help laboratory management understand the requirements of the 2009 TNI Standard. The material will "demystify" terminology, provide assistance in understanding the requirements, and provide guidance on how to incorporate the requirements of the Standard into laboratory operations without disrupting current practices. 41

42 Technical Assistance for Laboratories Small Laboratory Handbook Tips and Hints for implementing the standard Quality Manual Template Fill-in-the-blank template ready to tailor to any lab TNI Standard webcast 16-hour comprehensive training on the TNI Standard Listing of consultants to help laboratories How to get accredited flow chart Quality Systems checklist Standards Interpretations Small Laboratory Advocacy Group Fields of Proficiency Testing Tables List of Third-party Lab Assessors 42

43 Assessment Forum and Mentor Sessions Held in Conjunction with TNI Meetings Making Internal Audits Effective Internal Audits for Small Municipal Laboratories Practicing Root Cause and Corrective Action Microbiology QA/QC Requirements Meeting TNI Standard Requirements for Microbiology Writing Findings What a QA Officer Really Does Following the Yellow Brick Road to Managing Quality Top 10 Suggestions on Being a Better QA Officer and many more 43

44 Downloadable Webcasts Corrective Action Process and Root Cause Analysis Theoretical and Practical Consideration for Establishing Sensitivity of Measurements Internal Audits and Management Review Ethics Training for the Environmental Professional Establishing a Data Integrity Plan Defining Organizational Responsibilities Method Selection and Validation Etc 44

45 Audit Processes Assessment of Laboratory Operations On-site and through data review SOPs, data, PT performance, training, recordkeeping, sample receipt and handling procedures, equipment, etc. Assessment of Laboratory Personnel Laboratory Supervisor qualifications and capability, analyst training and competence Assessment of Laboratory Management System SOPs and Quality Manual, internal audits, management reviews, preventive actions, corrective actions, complaint investigations and resolution procedures, etc. 45

46 Most Common Findings From Assessments Not following SOP Data integrity training Internal audits Records 46

47 Examples of Data Integrity Training Improper Manual Integrations: Adding or removing peak area to have QC appear to pass Arbitrarily separating co-eluting peaks into separate compounds based on retention times Selecting the wrong peak so that the reported result is ND or <QL Arbitrarily selecting peak area that cannot be distinguished from instrument noise 47

48 Examples for Training Improper Manual Integrations removing area 48

49 How do you Implement the TNI Std Management Commitment to Quality beyond compliance corporate culture Defined Chain of Command and Reporting Responsibilities Ethics Training Continual Re-Assessment of Analytical Capability/Laboratory Capacity Management Reviews Continuous Monitoring and Training External Audits/Consultants Preventive Instrument Maintenance Standard Operating Procedures 49

50 Continued Compliance Corrective Action Report Root Cause Determinations Corrective Actions Follow-up on Effectiveness of Corrective Actions Self-Monitoring Re-training of Analysts Upgrade/Purchase New Instrumentation Manage staff, objectives, train, follow up 50

51 Tips from PA BOL Leadership Practice On-sites Lab Improvement Findings for one section may be applicable to lab Recommendations may be simplified Auditors are not the enemy There is no such thing as a perfect score 51

52 In Summary Accreditation reflects capability Accountability and compliance is the laboratory s responsibility Management is the first line of defense Focus on Preventive Action and Root Cause Investigations Findings are for laboratory improvement Reliable and defensible data means safer and healthier environments and citizens 52

53 QUESTIONS? Dr. Martina Q. McGarvey Director, Bureau of Laboratories Aaren S. Alger Chief, Laboratory Accreditation Program 53

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